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Old 1st Jul 2008, 01:43
  #33 (permalink)  
alf5071h
 
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Non-PC Plod whether provable or not, we agree that NTS will aid a safe outcome. However our opinions diverge on the evidence of pilot error from incidents, accidents, or LOSA.
Many accident reports (perhaps the more older ones) conclude pilot error, or CRM failure as causal factors, but these terms only state the outcome and not the reason for it (the old way of thinking about human error – Dekker).

Many of the errors reported by LOSA are outcomes; they do not uncover the underlying reasons for the behaviour.
Your example of unstabilised approaches from LOSA is a record of what happened; I have yet to see reasons why they happened. In one instance crews might be overly influenced by organisation pressure for on time arrivals or ATC requests (misappropriated goal), which could be considered NTS items. Alternatively, the approach procedure, aircraft configuration, weight, wind, rules / procedures may inevitably result in a fast approach, which being outside of the pilots control should not be a NTS issue – it’s a system / organisational weakness that require fixing. [You could assess the ability to identify the reasons for the fast approach and the attitude towards submitting a safety report – but that might be unfair].
I suggest that the majority of LOSA reports involve the latter situation, a system or organisational culture issue which result in violation. This is not to say that there are many occurrences of ‘press-on-it is’ (failure of cognition), but without discussion how can these be identified? Trained LOSA observers can help, but they are equally subject to bias and misperception. Is the inability to differentiate the unprovable aspect of cognitive NTS and a major weakness of LOSA?

As stated previously, NTS assessment has the advantage of discussion and to some degree control of perceptual or systems issues in ground training, but not so in airborne assessment.
Thus in-flight, if a fast approach is deemed a technical consequence, and that the underlying reason is not identified (differing opinions), then is this a NTS failure?
Not in my book; it’s a ‘no test’, there is insufficient information on which to make an assessment, but plenty for both parties to learn from.
As de Bono states (many books) there are positive, negative and ‘interesting’ aspects in most situations; I think that the majority of interesting aspects involve cognitive NTS.
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